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Obama remarks on health care

Obamacare won’t have a shot at success unless millions of people sign up for insurance — the healthy as well as the sick. For that to happen, the White House and its allies will need to make the case that coverage is worth it for the estimated 50 million people who haven’t been able to afford or access insurance. Supporters are planning to spend tens of millions of dollars to persuade people to get covered under new health insurance options and explain how to sign up.

Organizing for Action, spun off from President Barack Obama’s campaign operation, went up with a seven-figure TV ad buy in June, touting the new benefits and promising to offer “the truth” about the law. Enroll America, a nonprofit group with ties to the White House, wants to leverage the grass roots across the country and engage big-name celebrities for the cause.

Here are five of the messaging challenges they face:

Spread the word about the subsidy — without inflating expectations.

Just about everyone knows there’s an individual mandate in the health law — people must have insurance starting in 2014. But another part of the message didn’t get through: Millions of Americans, including some in the middle class, will get help to pay for that coverage. And low-income people won’t have to pay premiums if they qualify for expanded Medicaid.

It’s not entirely clear why the White House hasn’t hit that point harder: One reason may be that it doesn’t want to raise expectations and then crush them. Not everyone gets a subsidy. And subsidy doesn’t mean “free ” — it’s a sliding scale depending on income, location and family size. But some assistance is available up to four times the federal poverty level, or about $93,000 for a family of four.

“It’s very hard to explain the subsidies … so you end up avoiding it,” said Bob Blendon, an expert on health and public opinion at the Harvard School of Public Health. And old hands at health care remember what happened 25 years ago when Congress passed a law to help people with “catastrophic” Medicare expenses — and then had to repeal it when the overly high expectations collided with the cost-benefit realities.

Ethan Rome, executive director of Health Care for America Now, which strongly backs the law, predicts a massive multi-front education campaign that will start breaking through to people. And it will include a “retail” approach, particularly once enrollment opens Oct. 1.

“When you are talking to potential enrollees about the price of the insurance the best conversation you can possibly have is talking to them about their specific situation,” Rome said. Once people begin to get the subsidies and the coverage, he predicted positive word of mouth will encourage more people to sign up.

Lots of the people eligible for various government assistance programs don’t actually reach out for them, and that may prove true of the health law, too. A recent Gallup poll found the uninsured knew less about the law than the insured, including the individual mandate.

Many of those who could get Medicaid or subsidized coverage are low-income, and not necessarily English-speaking. They may not see slick ads on English-language TV, and experience shows they may need a lot more than a brochure and a URL to tap into the benefits. They need different messaging and outreach and a lot more hands-on assistance, said Stan Dorn, a Medicaid expert at the Urban Institute.

That’s a conundrum. People can’t be walked through enrollment before it starts in October. But the longer the administration waits to reach this population, the less time they’ll have to break through, said Bruce Siegel, head of America’s Essential Hospitals, whose members treat low-income populations. “Waiting for fall is too late,” he said. Outreach has to be now and it has to target a whole lot of different audiences, from the Spanish-language tweet to a message that can work in a Haitian hair salon in Brooklyn.

Not only that, but the Supreme Court made the law even more confusing for the poor by deciding Medicaid expansion is optional for states. In some states, poor people will get benefits from expanded Medicaid — and in others they’ll get nothing. Even more confounding — the below-the-poverty line Medicaid population can’t tap into the subsidies in the health insurance exchanges, but people who are just few rungs up the income ladder can get that financial help.

“That message is going to be complicated,” HHS Secretary Kathleen Sebelius said last week. “If the governor and legislature choose not to expand Medicaid, there will be a huge gap between what [low-income people] can afford and what is available.”

The “safety net” hospitals and community clinics will try to fill in the considerable awareness gaps when low-income and uninsured patients come in, said Siegel. But how well they do will depend partly on what state they are in, and how much of a buy-in state governments give to Obamacare.